Ambetter 90-Day-Maintenance Drug List- 2020 -Indiana

Ambetter 90-Day-Maintenance Drug List

Guide to this list:

What is Ambetter 90‐Day‐Maintenance Drug List?

Ambetter 90‐Day‐Supply Maintenance Drug List is a list of maintenance medications that are available for 90 day supply through mail order or through our Extended Day Supply Network.

How do I find a pharmacy that is participating in Extended Day Supply Network?

To find a retail pharmacy that is participating in our Extended Day Supply Network please consult information available under Pharmacy Resources tab on our webpage. Alternatively, you can utilize our mail order pharmacy. Information on mail order pharmacy is available in Pharmacy Resources tab on our webpage.

Are all formulary drugs covered for 90 day supply?

No, certain specialty and non‐specialty drugs are excluded from 90 day supply. Please consult 90‐Day‐ Supply Maintenance Drug List for information if your drug is included.

A Amlodipine Besylate-Atorvastatin Calcium Acamprosate Calcium Amlodipine Besylate-Benazepril HCl Acarbose Amlodipine Besylate-Olmesartan Medoxomil Acebutolol HCl Amlodipine Besylate-Valsartan Acetazolamide Amlodipine-Valsartan-Hydrochlorothiazide Albuterol Sulfate Amoxapine Alendronate Sodium Amphetamine-Dextroamphetamine Alendronate Sodium-Cholecalciferol Anagrelide HCl Alfuzosin HCl Anastrozole Aliskiren Fumarate Apixaban Allopurinol Arformoterol Tartrate Alogliptin Benzoate Aripiprazole Alosetron HCl Armodafinil Amantadine HCl Asenapine Maleate Amiloride & Hydrochlorothiazide Aspirin-Dipyridamole Amiloride HCl Atenolol Amiodarone HCl Atenolol & Chlorthalidone Amitriptyline HCl Atomoxetine HCl Amlodipine Besylate Atorvastatin Calcium

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Celtic Insurance Company. All rights reserved. 1-877-687-1182 (TTY/TDD 1-800-743-3333) 550 N. Meridian St Suite 101 Indianapolis, IN 46204 Ambetter.mhsindiana.com Auranofin Chlorothiazide Azathioprine Chlorpromazine HCl Azilsartan Medoxomil Chlorpropamide Chlorthalidone B Cholestyramine Beclomethasone Dipropionate HFA Cholestyramine Light Benazepril & Hydrochlorothiazide Cilostazol Benazepril HCl Cimetidine Benztropine Mesylate Cimetidine HCl Betaxolol HCl Citalopram Hydrobromide Betaxolol HCl (Ophth) Clobazam Betrixaban Maleate Clomipramine HCl Bimatoprost Clonidine Bisoprolol & Hydrochlorothiazide Clonidine HCl Bisoprolol Fumarate Clonidine HCl (ADHD) Brexpiprazole Clopidogrel Bisulfate Brimonidine Tartrate Colchicine w/ Probenecid Brimonidine Tartrate-Timolol Maleate Colesevelam HCl Brinzolamide-Brimonidine Tartrate Colestipol HCl Brivaracetam Conjugated Estrogens-Bazedoxifene Bromocriptine Mesylate Conjugated Estrogens-Medroxyprogesterone Bromocriptine Mesylate (Diabetes) Acetate Budesonide (Inhalation) Cromolyn Sodium Budesonide-Formoterol Fumarate Dihydrate Cyclosporine Bumetanide Cyclosporine (Ophth) Bupropion HCl Cyclosporine Modified (For Microemulsion) Cysteamine Bitartrate C Cysteamine HCl Calcitonin (Salmon) Calcitriol D Calcium Acetate (Phosphate Binder) Dapagliflozin Propanediol Candesartan Cilexetil Dapagliflozin-Metformin HCl Candesartan Cilexetil-Hydrochlorothiazide Dapsone Cannabidiol Darifenacin Hydrobromide Captopril Deferiprone Carbamazepine Desipramine HCl Carbamazepine (Antipsychotic) Desmopressin Acetate Carbidopa Desmopressin Acetate Spray Carbidopa-Levodopa Desmopressin Acetate Spray Refrigerated Carbidopa-Levodopa-Entacapone Desogestrel & Ethinyl Estradiol Carteolol HCl (Ophth) Desogestrel-Ethinyl Estradiol (Biphasic) Carvedilol Desogestrel-Ethinyl Estradiol (Triphasic) Celecoxib Desvenlafaxine Succinate Cevimeline HCl Dexlansoprazole Chloroquine Phosphate Dexmethylphenidate HCl

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Celtic Insurance Company. All rights reserved. 1-877-687-1182 (TTY/TDD 1-800-743-3333) 550 N. Meridian St Suite 101 Indianapolis, IN 46204 Ambetter.mhsindiana.com Dextroamphetamine Sulfate Escitalopram Oxalate Dextromethorphan HBr-Quinidine Sulfate Eslicarbazepine Acetate Diazoxide Esomeprazole Magnesium Diclofenac Potassium Esterified Estrogens Diclofenac Sodium Estradiol Diclofenac w/ Misoprostol Estradiol Acetate Vaginal Diflunisal Estradiol Vaginal Digoxin Estradiol Valerate-Dienogest Diltiazem HCl Estradiol-Levonorgestrel Diltiazem HCl Coated Beads Estrogens, Conjugated Diltiazem HCl Extended Release Beads Estrogens, Conjugated Vaginal Dipyridamole Ethacrynic Acid Disopyramide Phosphate Ethosuximide Disulfiram Ethotoin Divalproex Sodium Ethynodiol Diacet & Eth Estrad Dofetilide Etodolac Donepezil Hydrochloride Etonogestrel-Ethinyl Estradiol Dorzolamide HCl Ezetimibe Dorzolamide HCl-Timolol Maleate Ezetimibe-Simvastatin Doxazosin Mesylate Doxepin HCl F Doxercalciferol Famotidine Dronedarone HCl Febuxostat Drospirenone Felbamate Drospirenone-Ethinyl Estradiol Felodipine Drospirenone-Ethinyl Estradiol-Levomefolate Fenofibrate Calcium Fenofibrate Micronized Dulaglutide Fenoprofen Calcium Duloxetine HCl Fesoterodine Fumarate Dutasteride Finasteride Flavoxate HCl E Flecainide Acetate Echothiophate Iodide Fludrocortisone Acetate Empagliflozin Fluoxetine HCl Empagliflozin-Metformin HCl Fluoxetine HCl (PMDD) Enalapril Maleate Fluphenazine HCl Enalapril Maleate & Hydrochlorothiazide Flurbiprofen Entacapone Fluticasone Furoate (Inhalation) Eplerenone Fluticasone Furoate-Vilanterol Eprosartan Mesylate Fluticasone Propionate (Inhalation) Erenumab-aooe Fluticasone Propionate HFA Ergocalciferol Fluticasone-Salmeterol Ergoloid Mesylates Fluticasone-Umeclidinium-Vilanterol Ertugliflozin L-Pyroglutamic Acid Fluvastatin Sodium Ertugliflozin-Metformin HCl Fluvoxamine Maleate

H L Haloperidol Labetalol HCl Haloperidol Lactate Lacosamide Hydralazine HCl Lactulose Hydrochlorothiazide Lactulose (Encephalopathy) Hydroxychloroquine Sulfate Lamivudine (HBV) Hydroxyurea (Sickle Cell Anemia) Lamotrigine Lansoprazole I Lanthanum Carbonate Ibandronate Sodium Latanoprost Ibuprofen Leflunomide Icosapent Ethyl Lesinurad Imipramine HCl Lesinurad-Allopurinol Imipramine Pamoate Letrozole Indacaterol Maleate Levalbuterol HCl Indacaterol Maleate-Glycopyrrolate Levalbuterol Tartrate Indapamide Levetiracetam Indomethacin Levobunolol HCl Insulin Aspart Levomilnacipran HCl Insulin Aspart (with Niacinamide) Levonorgestrel & Eth Estradiol Insulin Aspart Protamine & Aspart (Human) Levonorgestrel-Eth Estradiol (Triphasic) Insulin Degludec Levonorgestrel-Ethinyl Estradiol & Folic Acid Insulin Degludec-Liraglutide Levonorgestrel-Ethinyl Estradiol (91-Day)

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Celtic Insurance Company. All rights reserved. 1-877-687-1182 (TTY/TDD 1-800-743-3333) 550 N. Meridian St Suite 101 Indianapolis, IN 46204 Ambetter.mhsindiana.com Levonorgestrel-Ethinyl Estradiol (Continuous) Mexiletine HCl Levonorgestrel-Ethinyl Estradiol-Ferrous Miglitol Bisglycinate Milnacipran HCl Levothyroxine Sodium Minoxidil Linaclotide Mirabegron Liothyronine Sodium Mirtazapine Liraglutide Misoprostol Lisdexamfetamine Dimesylate Modafinil Lisinopril Moexipril HCl Lisinopril & Hydrochlorothiazide Montelukast Sodium Lithium Mycophenolate Mofetil Lithium Carbonate Mycophenolate Sodium Losartan Potassium Losartan Potassium & Hydrochlorothiazide N Lovastatin Nabumetone Loxapine Succinate Nadolol Lubiprostone Naproxen Lurasidone HCl Naproxen Sodium Nateglinide M Nebivolol HCl Maprotiline HCl Nefazodone HCl Mecamylamine HCl Niacin (Antihyperlipidemic) Meclofenamate Sodium Niacin-Lovastatin Medroxyprogesterone Acetate Niacin-Simvastatin Mefenamic Acid Nicardipine HCl Mefloquine HCl Nifedipine Megestrol Acetate (Appetite) Nisoldipine Meloxicam Nitroglycerin Memantine HCl Nizatidine Mesalamine Norelgestromin-Ethinyl Estradiol Metaproterenol Sulfate Norethin Acet & Estrad-Fe Metformin HCl Norethindrone & Eth Estradiol Methamphetamine HCl Norethindrone & Ethinyl Estradiol-Fe Methazolamide Norethindrone (Contraceptive) Methimazole Norethindrone Acet & Eth Estra Methsuximide Norethindrone Acetate Methyclothiazide Norethindrone Acetate-Ethinyl Estradiol Methyldopa Norethindrone Acetate-Ethinyl Estradiol-Fe Methylphenidate Norethindrone Acetate-Ethinyl Estradiol-Fe Fum Methylphenidate HCl (Biphasic) Methyltestosterone Norethindrone-Eth Estradiol (Triphasic) Metolazone Norgestimate-Ethinyl Estradiol Metoprolol & Hydrochlorothiazide Norgestimate-Ethinyl Estradiol (Triphasic) Metoprolol Succinate Norgestrel & Ethinyl Estradiol Metoprolol Tartrate Nortriptyline HCl

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Celtic Insurance Company. All rights reserved. 1-877-687-1182 (TTY/TDD 1-800-743-3333) 550 N. Meridian St Suite 101 Indianapolis, IN 46204 Ambetter.mhsindiana.com Potassium Chloride Microencapsulated Crystals O ER Olanzapine Pramipexole Dihydrochloride Olmesartan Medoxomil Pramlintide Acetate Olmesartan Medoxomil-Amlodipine- Prasterone Vaginal Hydrochlorothiazide Prasugrel HCl Olmesartan Medoxomil-Hydrochlorothiazide Pravastatin Sodium Olodaterol HCl Prazosin HCl Olsalazine Sodium Pregabalin Omega-3-acid Ethyl Esters Pregabalin (Once-Daily) Omeprazole Primidone Omeprazole-Sodium Bicarbonate Probenecid Ospemifene Prochlorperazine Maleate Oxaprozin Progesterone Micronized Oxcarbazepine Propafenone HCl Oxybutynin Chloride Propranolol HCl Propylthiouracil P Protriptyline HCl Paliperidone Pancrelipase (Lipase-Protease-Amylase) Q Pantoprazole Sodium Quetiapine Fumarate Paricalcitol Quinapril HCl Paroxetine HCl Quinapril-Hydrochlorothiazide Pentoxifylline Quinidine Sulfate Perampanel Perindopril Erbumine R Perphenazine Rabeprazole Sodium Perphenazine-Amitriptyline Raloxifene HCl Phenelzine Sulfate Ramipril Phenobarbital Ranitidine HCl Phenytoin Ranolazine Phenytoin Sodium Extended Rasagiline Mesylate Pilocarpine HCl Repaglinide Pilocarpine HCl (Oral) Repaglinide-Metformin HCl Pimozide Rifaximin Pindolol Riluzole Pioglitazone HCl Risedronate Sodium Pioglitazone HCl-Glimepiride Risperidone Pioglitazone HCl-Metformin HCl Rivaroxaban Piroxicam Rivastigmine Tartrate Pitavastatin Calcium Roflumilast Posaconazole Ropinirole Hydrochloride Potassium Bicarb & Chloride Rosiglitazone Maleate Potassium Bicarbonate Rosuvastatin Calcium Potassium Chloride Rotigotine

T U Tacrolimus Umeclidinium Bromide Tadalafil Umeclidinium-Vilanterol Tafluprost Ursodiol Tamoxifen Citrate Tamsulosin HCl V Tasimelteon Valganciclovir HCl Telmisartan Valproate Sodium Telmisartan-Amlodipine Valproic Acid Telmisartan-Hydrochlorothiazide Valsartan Terazosin HCl Valsartan-Hydrochlorothiazide Terbutaline Sulfate Venlafaxine HCl Testosterone Verapamil HCl Theophylline Vilazodone HCl

W Warfarin Sodium

Z Zafirlukast Zileuton Ziprasidone HCl Zonisamide